Behavioral Healthcare Forms

*All elements on Demographic section are required. If no employer, please put Not Applicable.)

I hereby authorize payment directly to Duke City Primary Care, parent company of Duke City Behavioral Healthcare, for services rendered and supplies provided by Duke City Behavioral Healthcare. I understand that this assignment is for all benefits otherwise payable to me, but not to exceed my indebtedness to said Clinic. I authorize Duke City Primary Care, parent company of Duke City Behavioral Healthcare, to release any information acquired in the course of treatment or examination. I understand that I am financially responsible to Duke City Primary Care, parent company of Duke City Behavioral Healthcare, for charges not covered by this assignment. I authorize the release of any and all behavioral health information necessary to process these claims and I request payment of any benefits due to me or for my benefits to be made directly to Duke City Primary Care, parent company of Duke City Behavioral Healthcare.

1. Diagnosis
2. Treatments
3. Results of tests performed from present and past visits for future medical determinations.

1. The clinic will use and disclose your PHI in coordination and management of your health care and any related behavioral health services.
2. A sign in sheet will be used and visible to other clients, staff and those who enter the clinic. The use of the sign in sheet will be strictly for business related practices.
3. PHI will be used for coordination and management of your medical needs with a third-party provider, for reason of treatment for continued behavioral health care. In some cases, we may also disclose information to an outside treatment provider for purposes of the treatment activities of the other provider (for example, disclosing PHI to a pharmacy to fill a prescription or to obtain results of a lab test not available on site).

1. Your PHI will be used as needed to obtain payment for all services rendered and/or required. This includes any communications between payer sources and the practice (for example, services may require prior authorization for services, insurance payer would be contacted to obtain information regarding benefits, eligibility, and medical necessity).

1. Public health authorities are authorized by law to collect or receive information or controlling disease, injury, or disability and to release to public health or other government authorities authorized to receive reports of child abuse and neglect.
2. FDA regulation regarding FDA regulated products or activities for purposes such as adverse event reporting, tracking of products, product recalls, and post marketing surveillance.
3. Individuals who may have contracted or been exposed to a communicable disease when notification is authorized by law.
4. Employers, regarding employees, when requested by employers, for information concerning a work-related illness or injury or workplace related medical surveillance.
5. Victims of Abuse, Neglect, or Domestic Violence. In certain circumstances, regulations require disclosure of PHI to appropriate government authorities regarding victims of abuse, neglect, or domestic violence.
6. Health Oversight Activities may require PHI to be disclosed for the purpose of legally authorized audits and investigation necessary for oversight of the health care system and government benefit programs, by such agencies as assigned by the government.
7. Judicial and Administrative Proceedings may require the disclosure of PHI through an order from a court or administrative tribunal. This may be in response to a subpoena or other lawful process.
8. Law Enforcement Purposes may require PHI to be disclosed to law enforcement officials for law enforcement purposes under the following six circumstances and subject to specified conditions:
   1. As required by law (including court orders, court-ordered warrants, subpoenas) and administrative requests.
   2. To identify or locate a suspect, fugitive, material witness, or missing person.
   3. In response to a law enforcement official’s request for information about a victim or suspected victim of a crime.
   4. To alert law enforcement of a person’s death, if the covered entity suspects that criminal activity caused the death.
   5. When a covered entity believes that PHI is evidence of a crime that occurred on its premises, and
   6. By a covered health care provider in a medical emergency not occurring on its premises, when necessary, to inform law enforcement about the commission and nature of a crime, the location of the crime or crime victims, and the perpetrator of the crime.

1. To review and obtain a copy of your PHI in your medical record. (A fee may be charged for copying and/or printing medical records as permitted by law).
2. To request that DCBH, a division of DCPC restricts use or disclosure of PHI for treatment, payment or health care operations, disclosure to persons involved in the individual’s health care or payment for health care, or disclosure to notify family members or others about the individual’s general condition, location, or death.
3. To request an amendment of your PHI in your medical record when the information is inaccurate or incomplete.
4. To disclose all accounts of your PHI by DCBH, a division of DCPC or other behavioral health/medical providers or entities.

1. We are required to maintain the privacy of your health information and to provide you with the notice of our duties and privacy practices.
2. We are required to abide by terms of this notice and to make the new notice provisions effective for all future PHI that we maintain. DCBH, a division of DCPC reserves the right up update, change, or amend this policy. If we change the notice, we will provide a copy to any persons with such request by means of in person or via email and the update will be posted in our waiting area.
3. As a health care provider, we will in good faith make an effort to obtain written acknowledgment of your receipt of the privacy practices notice to you.

If you have any questions or concerns regarding this Notice of Privacy Practices or feel your rights have been violated, contact the HIPAA Privacy Officer of DCPC at: 12127 B State Hwy 14 N Suite 5 Cedar Crest, NM 87008 during business hours or contact (505) 281-5180. You may also file a written complaint to the US Dept. of Health and Human Services, Office for Civil Rights at 1301 Young Street Suite 1169 Dallas, Texas 75202. You will not be retaliated against or penalized for any complaints filed against or any issues brought to the attention of the practice.

Behavioral Health (BH) is a term referring to mental health and substance use conditions. By voluntarily consenting to participate in treatment, you understand that services can be offered by various BH providers to include a psychologist, social worker, counselor or psychiatric nurse practitioner licensed in the State of New Mexico. Treatment can be a combination of interviews, assessment, testing, therapy and/or medication. At times and with your consent, collaboration with your primary care provider (PCP) may be utilized to enhance the effectiveness of treatment. We view treatment as a relationship between people. Clients have clearly defined rights and responsibilities as explained within this document. These rights and responsibilities are important for you to understand. There are also requirements for your BH providers which are important for you to understand.

BH treatment is different than a visit with your PCP. It calls for very active and involved participation from the client. For treatment to be most successful, you will have to work on things in between sessions. BH services have both benefits and risks. Services often involve discussing unpleasant aspects of your life. Risks may include experiencing uncomfortable feelings; however, involvement in treatment has also been shown to have benefits.It can lead to a reduction in feelings of distress, increased satisfaction in relationships, and resolutions to specific problems. A small number of clients may not improve with treatment or may terminate before improvement. Although no guarantees can be made about what will happen throughout the course of treatment, most people do experience improvement in symptoms. it is important to keep your BH provider informed of any difficulties you may encounter as it arises.

The first several sessions will involve a comprehensive assessment of your needs. By the end of the evaluation, BH providers will be able to offer you some initial impressions. In collaboration with you, a treatment plan will be completed. If you have questions please feel free to ask them at any point within the course of treatment. If your treatment needs would be best addressed through another BH provider, or treatment is discontinued for any reason specified within this consent, or for services not offered through DCBH this will be discussed with you. Referrals can and will be provided as needed. ent plan will be completed. It is important for you to evaluate all this information and determine if you feel comfortable proceeding with treatment, as well as, comfortable with the Behavioral Health provider. If you have questions about the treatment interventions used, treatment plan, etc. please feel free to ask them at any point within the course of treatment. In the event that the treatment needs would be best addressed through another Behavioral Health provider, treatment is discontinued for any reason specified within this consent, or for services not offered through Duke City Behavioral Healthcare, a division of Duke City Primary Care, this will be discussed with you. Referrals can and will be provided as needed.

Appointments will ordinarily be 45-50 minutes in duration. Sessions are likely to occur once a week or every two weeks, although some sessions may be less frequent as needed. The time scheduled for your appointment is assigned to you You are responsible for coming to your appointment on time. If you are late, your appointment will still need to end on time. If there is not enough time to complete a session based on being late, your appointment may be cancelled and rescheduled for another time. This may result in a $25 fee. If you need to cancel a session, please provide at least 24 hours’ notice. If you do not call or cancel your appointment 24 hours prior to the scheduled appointment and elect not to attend your appointment, you will be charged a $25 fee unless prohibited by insurance contract.

For all referrals to BH, a referral will remain open for a minimum of 14 days to contact the client. If a client is not interested in services, the referral will be closed. If a client is interested in services but has not completed any paperwork required for scheduling within 30 days of receipt of referral, the referral will be closed. If a client completes all requirements for scheduling but cancels or no-shows for the initial appointment, the client will be placed on the waitlist until another appointment can be scheduled with a provider. No more than two cancellations or no-shows will be allowed for an initial intake appointment. If this occurs, the referral will be closed. A list of referral agencies is maintained for community agencies and can be provided.

The typical course of therapy is that clients come to the end of counseling following completion of all treatment goals. After the final session, the clinical case is closed. It is important to note that cases can be closed for other reasons to include but not limited to: client requests to discontinue services; a need for services not provided within DCBH; insurance authorization expires or number of authorized sessions have been exhausted and self-pay is not an option for client; virtual services are no longer considered appropriate; inappropriate conduct towards Duke City staff despite prior unsuccessful attempts to correct behavior; or duplication of services without outside BH provider, etc.

In the event a client completely stops attending sessions for a period of 45 days, without notifying BH , the clinical case will be closed by default. A client can always return to counseling after their case has been closed. They will, however, need to go through the formal process of having their case reopened and a waiting period will apply. The formal referral process will include at a minimum a new referral and update of paperwork if outdated.

DCBH establishes all rates for BH services provided. Co-pay rates are established by your insurance carrier. All professional services rendered are charged to the client. It is customary to pay for services when rendered unless arrangements are made in advance. Necessary forms will be completed to expedite insurance payment.

• • For individuals who will not be utilizing insurance and will be self-pay, please contact our Program Support Specialist in Behavioral Health at (505) 944-9495(505) 944-9495 to get a fee schedule.
• For individuals who are out-of-network, please contact your insurance carrier to inquire on your financial responsibility for services. If you are needing a fee schedule, please contact our Program Support Specialist in Behavioral Health at (505) 944-9495.

For telephone calls lasting greater than 11 minutes, a bill and the accompanying documentation will be entered. This may result in a financial obligation for you if your insurance does not cover the service. If you require any forms to be completed for work, school, Family Medical Leave Act, no fee is required. However, please ensure you have forwarded the forms to the BH provider in time for your appointment. For additional information on completion of forms, please discussion with the administrative staff or BH provider. For litigation or court proceedings involving subpoenas, fees will apply. Please contact the BH office at (505) 944-9495 for the fee schedule.

Per the Duke City financial policy, staff will collect co-pay prior to being seen by the BH provider. If for any reason you are unable to meet the financial responsibilities for services, please contact the billing office for options at 505-814-1996. In the event the client is unable to may any payments as part of a payment plan, the client will not be permitted to be seen, temporarily, unless their condition presents an immediate risk/danger to self or others. Once stability is assessed, no additional sessions will be scheduled until the account has been paid. The case will remain open for 90 days for the client to arrange payments and bring account into good standing. DCBH has the option of using legal means to secure the payment. This may involve using a collection agency or going through small claims court unless prohibited by state mandate or insurance contract. If such legal action is necessary, you will be responsible for any associated costs.

If you have a health insurance policy, it may provide some coverage for behavioral health services. Necessary forms will be completed by DCBH to expedite insurance payment. This includes obtaining the necessary pre-authorization for services at the initiation of treatment and throughout the course of treatment if required. It is your responsibility to inform us of any changes in insurance carriers or discontinuation of coverage.

As explained in the Notice of Privacy Practices, the use of your protected health information (PHI) will be used for coordination and management of your behavioral health needs with a third-party provider (i.e., your insurance carrier). Upon your request, we will provide you with a copy of any records submitted to your insurance carrier if you request it. You understand that, by using your insurance, you authorize Duke City Behavioral Healthcare to release such information to your insurance company. We will try to keep that information limited to the minimum necessary. It is important to remember that you always have the right to pay for these services yourself to avoid the problems described above, unless prohibited by the insurance contract. For additional information, please refer to the DCBH Financial Policy and the Notice of Privacy Practices.

Due to the rising costs of health care, insurance benefits have increasingly become more complex. It is sometimes difficult to determine exactly how much mental health coverage is available. Managed Health Care plans such as HMOs and PPOs often require advance authorization, without which they may refuse to provide reimbursement for behavioral health services. These plans are often limited to short-term treatment approaches designed to address specific problems interfering with a person’s usual level of functioning. It may be necessary to seek approval for treatment after a certain number of sessions. Although a great deal of work can be accomplished in short-term therapy, some individuals feel that they need more services after insurance benefits end. Some managed-care plans may not allow us to provide services to you once your benefits end. If this is the case, a referral can be provided to the agency/individual you desire with a signed consent.

As explained in the Notice of Privacy Practices, the use of your protected health information (PHI) will be used for coordination and management of your behavioral health needs with a third-party provider (i.e., your insurance carrier). Your PHI will be used as needed to obtain payment for all services rendered and/or required. You should be aware that most insurance companies require your Behavioral Health provider to give them a clinical diagnosis. At times, additional clinical information may have to be provided such as treatment plans, progress notes and on rare occasions, the entire clinical record. This information will become part of the insurance company files. Though all insurance companies claim to keep such information confidential, Duke City Behavioral Healthcare, a division of Duke City Primary Care, has no control over what they do with your information once it is in their possession. In some cases, they may share the information with a national medical information databank. We will provide you with a copy of any records submitted if you request it. You understand that, by using your insurance, you authorize Duke City Primary Care, parent company of Duke City Behavioral Healthcare to release such information to your insurance company. We will try to keep that information limited to the minimum necessary. It is important to remember that you always have the right to pay for these services yourself to avoid the problems described above, unless prohibited by the insurance contract.

In general, the privacy of all communications between a client and a BH provider is protected by law. It can only be released with your written permission as outlined within the Notice of Privacy Practices provided to you. The few exceptions that impact behavioral health services are outlined below. For review of all limitations, please refer to the Notice of Privacy Practices.

• Under New Mexico law, every BH provider who knows or has reasonable suspicion that a child is being abused or neglected, shall report the matter immediately to the appropriate state agency.
• Under New Mexico law, every BH provider who knows or has reasonable suspicion that an incapacitated adult is being abused, neglected, or exploited, shall report the matter immediately to the appropriate state agency.
• Every BH provider may disclose confidential information without the written consent of the client when the provider judges that releasing this information is necessary to protect the client from a substantial and imminent risk of serious self-harm.
• Every BH provider may disclose confidential information without the written consent of the client when the provider judges that releasing this information is necessary to protect a substantial and imminent risk of serious harm being inflicted by the client to another person.
• Every BH provider may release confidential information upon court order, or to conform to state or federal law, rules, or regulations.
• There may be occasions when your BH provider may find it helpful to consult with another professional about your treatment. In such cases, no information will be shared that could lead to identifying who you are. The information shared will be limited to the extent necessary to achieve the purposes of the consultation. Consultations occur in a private location with other professionals who are also bound by the same confidentiality laws.

To contact a BH provider, please call DCBH at (505) 944-9495. Please do not send an email or text message to our staff if you have an emergency or serious problem. During regular business hours, our agency strives to have phones answered promptly by our office staff. If a BH provider is not seeing a client, he or she will do everything possible to take the call. Often times, however, the BH provider is not immediately available. Phone calls are not answered when the provider is with clients During these times, you may leave a message on the BH provider’s confidential voice mail or speak with the administrative staff. Your call will be returned as soon as possible.

Please be aware that there are no afterhours or on-call providers within behavioral health. If you feel unable to keep yourself safe due to a serious or emergent issue, call 9-1-1 or go to your local emergency room hospital. You can also call the following crisis lines to speak with a BH provider:

Due to the personal nature of BH services, our relationship must be professional and not extend beyond the scope of services. We are unable to trade professional services, have contact outside of the work setting to include social networking internet sites such as Facebook, Instagram, Twitter, etc. If you are scheduled with a BH provider at our agency with whom you have a pre-established personal relationship, all efforts will be made to schedule you with another internal provider. If no other internal provider is available or if you prefer, a referral can be provided to an external provider as needed.

All clients at DCBH have the following rights:

• To be treated with dignity, courtesy, and respect from all staff.
• To access treatment regardless of race, color, religion, national origin, age, sex orientation, gender identity, marital
status, family status, disability, Veteran status, or any other legally protected group status.
• Every consideration of privacy concerning your care as outlined in the Notice of Privacy Practices and the Consent to
Behavioral Health Treatment form.
• To receive information regarding diagnosis and treatment provided in terms that are easily understood.
• To ask questions and receive answers about services.
• To participate fully in all decisions about treatment or services. This includes providing informed consent to participate in all services. In the event that a client is unable to give informed consent, attempts will be made to provide the information to the client to the extent possible while also obtaining written informed consent from a legally responsible party.
• To understand the financial obligations for treatment.
• To request a change in treatment or services. This includes the right to a new intake with another BH provider should you feel a second opinion is needed or you desire another clinician. In the event that a client requests a new intake with another provider, financial obligations and treatment limitations may occur subject to insurance carrier limitations and availability within DCBH.
• To refuse assessment and/or treatment unless a Court order is in place to participate.
• To discontinue treatment at any time.
• To have family involved in your treatment or to refuse involvement of family in your treatment.
• To participate fully in decisions regarding discharge from treatment including planning for continued care if needed.
• To request a review of your records and decide who else may do so with appropriate prior written authorization.

• Participate in your treatment in a cooperative and respectful manner. BH providers reserve the right to terminate treatment due to the client's failure to comply with treatment recommendations, failed appointments, and/or financial delinquencies. BH providers also reserve the right to terminate treatment based on the client and/or client’s family members exhibiting any written, verbal or physical threats, harassment, or foul language towards any staff.
• Be courteous to other clients and staff.
• Respect the property of DCBH, including the parking lot, waiting area, restrooms, and any assessment or treatment materials utilized during your services. This includes use of text or email modalities.
• Maintain financial responsibility for all payment of services. This includes following any no-show and cancellation policies set forth by the agency.
• Communicate with our staff. Staff are committed to best practice. You are responsible to let our staff know if you have any questions or problems.

You hereby authorize and consent to be treated by Behavioral Health providers and staff of Duke City Behavioral Healthcare, a division of Duke City Primary Care. The undersigned acknowledges having read and understood the above information and having had an opportunity to ask questions about this information and has voluntarily executed this document. If applicable, you also attest that you are the legal responsible party and have the right to consent for the treatment for the client identified.

1. As stipulated in NMSA 32A-6A-14, 15, a child under the age of 14 may consent to initial assessment and early intervention services, limited to verbal therapy, not to exceed a two-week period. After the initial period, parental consent is required.
2. As stipulated in NMSA 32A-6A-14, 15, a child 14 years or older has the right to consent to and receive individual psychotherapy, group psychotherapy, guidance counseling or other forms of verbal therapy and information regarding such treatment is confidential.
3. As stipulated in NMSA 32A-6A-14, 15, a child 14 years or older has the right to consent to psychotropic medication with notice to the parent/legal guardian.
4. As stipulated in NMSA 32A-6A-14, 15, a child 14 years or older has the exclusive right to consent to disclosure of their mental health records.

1. As stipulated in NMSA 32A-6A-14, 15, a child under the age of 14 may consent to initial assessment and early intervention services, limited to verbal therapy, not to exceed a two-week period. After the initial period, parental consent is required.
2. As stipulated in NMSA 32A-6A-14, 15, a child 14 years or older has the right to consent to and receive individual psychotherapy, group psychotherapy, guidance counseling or other forms of verbal therapy and information regarding such treatment is confidential.
3. As stipulated in NMSA 32A-6A-14, 15, a child 14 years or older has the right to consent to psychotropic medication with notice to the parent/legal guardian.
4. As stipulated in NMSA 32A-6A-14, 15, a child 14 years or older has the exclusive right to consent to disclosure of their mental health records.

Telemental Health services have both benefits and risks. One of the benefits of Telemental Health is that the client and BH provider can engage in services without being in the same physical location. It can also be more convenient and takes less time. Research shows that Telemental Health is about as effective as face-to-face treatment.

There are some differences between face-to-face treatment and Telemental Health. Telemental Health requires technical competence for both the clients and BH providers to be helpful. Because visits/sessions take place outside of the BH provider’s private office, there is potential for other people to overhear visits/sessions if you are not in a private place during the visit/session. Your BH provider will take reasonable steps to ensure your privacy. It will be important for you to make sure that you are in a private place for your visit/session where you will not be interrupted. You should participate in your visit/session only while in a room or area where other people are not present and cannot overhear the conversation. It will also be important to participate in your visit/session when you are not engaged in an activity that requires concentration such as driving.

There are many ways that technology issues might impact Telemental Health services. For example, technology may stop working during a session. Typically, your BH provider will not engage in Telemental Health services with clients who are currently in a crisis situation that require high levels of support and intervention. Before engaging in services, we will develop an emergency response plan to address potential crisis situations that may arise during the course of our Telemental Health work. Although no guarantees can be made about what will happen throughout the course of Telemental Health treatment, it is important to keep your BH provider informed of any difficulties you may encounter as they arise.

The same fee rates will apply for Telemental Health as apply for face-to-face behavioral health treatment. We will assist with verifying and completing paperwork for insurance to include authorization and Telemental Health coverage. Additional information and requirements for fees, payment and insurance can be located in the Behavioral Health Consent to Treatment form in the event you would like to self-pay for services.

All BH providers have a legal and ethical responsibility to protect all communications that are a part of Telemental Health services. Given the nature of electronic communications technologies, no guarantees can be made that the communications between BH providers and clients will be kept confidential or that other people may not gain access to these communications. DCBH uses updated encryption methods, firewalls, and back-up systems to help keep your information as private and secure as possible. As a client, you are strongly encouraged to take reasonable steps to ensure the security of our communications. For example, it is recommended that you use only secure networks for Telemental Health services and to use passwords to protect the device you are using whether it be a computer or cell phone. The extent of confidentiality and the exceptions to confidentiality that have been outlined in the Behavioral Health Consent to Treatment form still apply in Telemental Health services. Please let your BH provider know if you have any questions about exceptions to confidentiality.

Assessing and evaluating threats and other emergencies can be more difficult when conducting Telemental Health services than in traditional face-to-face services. To address some of these difficulties, it is imperative that an emergency plan be developed prior to engaging in Telemental Health services. You are asked to identify an emergency contact person who is near the location where you will complete your Telemental Health visit/session, which will typically be in your home. This will be the person who your BH provider will contact in the event of a crisis or emergency to assist in addressing the situation. As part of this consent, you are asked to sign a separate authorization form allowing the BH staff to contact your emergency contact person only as needed during such a crisis or emergency.

The following process will be utilized if the visit/session is interrupted during a crisis/emergency situation:

If the session is interrupted for any reason, such as the technological connection fails, do not attempt to reconnect or call the BH provider. If you feel unable to keep yourself safe due to a serious or emergent issue, call 9-1-1 or go to your local emergency room hospital. Call your BH provider after you have called or obtained emergency services.

The following process will be utilized if the visit/session is interrupted during a non-crisis/non-emergency situation:

If the session is interrupted for any reason, such as the technological connection fails, disconnect from the visit/session. Wait a few minutes and then re-connect to the visit/session via Zoom similar to how the visit/session was started. Your BH provider will also re-connect in the same manner. If after five (5) minutes, you and the BH provider have not re-connected through Zoom, the BH provider will call you at the phone number you provided at the beginning of the visit/session to discuss how to proceed with the visit/session.

If there is a technological failure and we are unable to resume the connection, you will only be charged the prorated amount of actual session time. For additional information on contacting the crisis line, please refer to the Behavioral Health Consent to Treatment form.

DCBH utilizes Zoom for Telemental Health services. The version used has the security and encryption required to maintain secure connections while the visit/service is occurring. Additional technology, such as mobile application or email, can be utilized throughout the course of treatment. You may require certain computer or cell phone systems to participate in Telemental Health services. You are solely responsible for any cost to obtain any necessary equipment, accessories, or software to participate in Telemental Health services.

Treatment is most effective when clinical discussions occur at the client’s regularly scheduled visits/sessions. However, on rare occasions, communication may be needed between visits/sessions due to an issue arising. Please call the BH office at (505) 944-9495. Email messages are used only for administrative purposes or to send not confidential information. Texts are used only for appointment reminders or links for paperwork. Because DCBH cannot guarantee the confidentiality of any information communicated by text or email, no clinical information will be shared through those modalities. Please do not send a message to our staff if you have an emergency or serious problem. If you need a response in less than two (2) business days, please call your BH provider’s office.

It is important to know that we make every attempt to respond to secured messages and telephone calls promptly. If a Behavioral Health provider is not seeing a client, he or she will do everything possible to take the call or respond to the secured Experity patient care portal message quickly. Often times, however, the Behavioral Health provider is not immediately available. Phone calls and Experity portal messages are not answered when the provider is with clients or otherwise unavailable. During these times, you may leave a message on the Behavioral Health provider’s confidential voice mail. Your call will be returned as soon as possible.

There may be occasions where you to do not hear from your provider quickly due to unforeseen reasons. This may include difficulty reaching you, the provider being out on leave, your call occurred during non-business hours, etc.Please be aware that there are no afterhours or on-call providers within behavioral health . If you feel you cannot wait for a return call or if you feel unable to keep yourself safe due to a serious or emergent issue, call 9-1-1 or go to your local emergency room hospital. You can also call the following crisis lines to speak with a Behavioral Health provider.

The Telemental Health visits/sessions will not be recorded in any way unless agreed to in writing with the consent of both client and BH provider.

Not all clients or treatment interventions are appropriate for Telemental Health services. An example of this would be clients who are at high risk or need extensive support between visits/sessions. If it is determined that face-to-face visits/sessions may be the most appropriate form of treatment for you, the BH provider will discuss options for face-to-face care. Referrals to another professional in your location may be required.

This agreement is intended as a supplement to the Consent to Behavioral Health Treatment and does not amend any of the terms of that agreement. Your signature below indicates that you have read and understand the above information, have had an opportunity to ask questions about this information, and consent to Behavioral Health treatment through Duke City Behavioral Healthcare, a division of Duke City Primary Care, as outlined above. As part of Telemental Health services delivered, you also agree to keep your camera on throughout the course of the sessions to maintain visual contact with the BH provider. If applicable, you also attest that you are the legal responsible party and have the right to consent for the treatment for the client identified.

I hereby authorize staff with Duke City Behavioral Healthcare, a division of Duke City Primary Care

To Release written or verbal information to include behavioral health records of myself concerning the following: